18460份计算机打印病历单项否决项目分析

Line-itemveto Problems Analysis of 18460 Computer-printing Medical Records

目的分析计算机打印病案单项否决项目产生的原因,探讨提高病案质量的有效方法及规范化管理的措施。方法按照卫生部颁布的《病历书写基本规范》、《住院病案首页部分项目填写说明》的具体要求,对2006年1月至2011年12月18460份计算机打印病历进行终末质量控制,利用SPSS17.0统计学软件对单项否决情况进行统计分析。结果手术科室病案甲级率(89.88%)明显低于非手术科室(95.48%)(χ2=189.562,P<0.01),终末病案甲级率的下降有93.8%同单项否决率有关〈^Y(甲级率)=0.995-1.145X(单项否决率),P<0.01〉。丙级病案1199份,丙级率6.5%。结论单项否决项目的缺陷是造成病案质量下降,尤其是丙级病案产生的主要原因。应查找原因,建立有效的管理方法,减少单项否决项目的发生。

Objective To analyze the cause of line-itemveto problems of computer-printing records and to improve the quality of medical records management.Methods To assess the final quality of 18460 medical records during 2006 to 2011 according to ＂medical record writing basic norms＂and ＂The front sheet of medical records filling explanation＂.Using SPSS17.0 statistics software to analyze line-itemveto.Results Compared to non-surgical departments（95.48%）,the quality of medical records of surgical departments（89.88%） was significantly low（χ2=189.562,P0.01）,the quality of medical records was strongly associated with the rate of line-itemveto （the rate of class A）=0.995-1.145X（the rate of line-itemveto）,P0.01.There were 1199 class C medical record,class C rate was 6.5%.Conclusion The defect of line-itemveto is the main cause of medical record quality decline,especially the class C medical record.We should find the reasons,set up effective management,reduce the occurrence of line-itemveto.